HIV Prevention: What Have We Learned From Community Experiences in Concentrated Epidemics?

XVII International AIDS Conference Plenary Session, Day 5

From kaisernetwork.org

August 8, 2008

Jean François Delfraissy: Again, good morning to everybody, my name is Jean François Delfraissy, I am the Director of the ANRS, a French National Agency on AIDS Research.

First, congratulations to the IAS [International AIDS Society], and the co-organizers and to the Mexicans colleagues for organizing this splendid and beautiful meeting Thanks a lot.

Human and social science are high priority in the research agenda of ANRS. However, we need more integration of human and social science with clinical science. For the long term evaluation of HAART-treated patients undetectable viral load and CD4 counts of 500 are necessary, but not sufficient. What is the goal of therapy in a chronic disease? Biological or social?

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In France, for example, 45 percent of treated patients do not work at that time. We need more collaboration between the two communities. In this context, I am very pleased to introduce Bruno Spire. Bruno is a researcher living with HIV. He is currently also President of AIDES, the primary NGO HIV organization in France. Bruno Spire was trained as a medical doctor in Paris. He obtained his PhD in virology in the lab of Françoise Barré-Sinoussi in the Pasteur Institute. He started a post-doctoral position in London in Professor Robin Weiss's lab to study the Vif protein of HIV virus. Then he returned to Marseille to continue in the same lab to study HIV in the field of molecular biology. That was the first part of his scientific life. Dr. Spire turned his research to public health issues in order to reconcile the objectives of scientists and activists. He has been involved in multidisciplinary studies in order to study patients' reported outcome in HIV untreated in our studies in court and in clinical trials. He also led a large number of analyses on the issue of patient adherence, demonstrating that adherence cannot be predicted in advance solely on the basis of social demographic characteristic. In contrary, his research demonstrates that adherence is influenced by the patient experience. Dr. Spire's research has contributed to the knowledge of determinants of patients' quality of life in the HAART era. Part of his research was focused on the sexual behavior of patients living with HIV.

A lot of this work has been funded by the ANRS. For the ANRS Bruno Spire is a real, real positive scientist, with a good interaction. In the future, Dr. Spire is interested in developing a research program that helps to address the needs of the community. He also wants to build international partnerships with other community based NGO's. Dr. Spire is an advocate for the rights of minorities, gay men, injecting drug users, and migrants to obtain equal access to healthcare. Bruno.

Bruno Spire, Ph.D.: Thank you, Jean François for these nice words. Buenos dias, todos. Good morning, everybody. Bonjour tous. In this presentation, I will not attempt to review the full range of prevention topics. As a virologist turned social scientist and as an activist, I would rather bring to your attention some lessons learned from community experiences in concentrated epidemics that should serve to improve prevention activities.

Despite the major progress in the field of HIV care, we only have in hand a limited number of proven HIV prevention approaches, while others are still at the research stage. The challenge is to scale up all HIV prevention strategies that are known to work. An example of a newly proven HIV prevention approach is male circumcision, but it will not fulfill all prevention needs. There is abundant evidence that harm reduction reduces HIV transmission among injecting drug users. Interventions promoting sexual risk reduction in particular through condom use, can reduce sexual transmission of HIV.

However, the narrowly conceived ABC [Abstinence, be faithful, use a condom] strategy has limitations. Abstinence only programs do not work. Interventions promoting partner reduction have had limited success among higher risk segments of the population. Finally, lifelong consistent condom use is not acceptable or feasible for most people.

I will explore in my presentation three actions that have the potential for improving our efforts to reduce the sexual transmission of HIV. These are combating prevention fatigue, diversifying HIV testing, and being effective against stigma.

Firstly, I would like to talk about prevention fatigue. But whose fatigue are we talking about? Is it the fatigue of prevention promoters or the people they are trying to reach? Adopting an approach which is more tailored to the needs of individuals might be helpful. The prevention discourse is often preached in all or nothing terms, while the concept of risk reduction has not been sufficiently explored.

Prevention fatigue has been raised as an issue for the gay community in most industrialized countries. In France, repeated cross sectional studies carried out among readers of the gay press found that the rate of unprotected anal intercourse increased from 20-percent in the 90's to 33-percent in 2007. The gay community has been widely criticized for insufficient action. However, as shown on this busy table, which describes a national French survey on sexual behavior, the gay community has greater comfort levels with condom use than other segments of the population. The proportion of people who use condoms is much higher in the MSM population, whatever the type of partnership or the number of sexual partners.

Instead of regretting the times when so many members of the gay community died despite widespread community action, it would be more constructive for all of us to work at developing pragmatic solutions for those who do not consistently use condoms. Understanding the conditions of risk and how people interpret risk is of key importance. On this slide, you can see different situations drawn from real life where systematic condom use is just not happening. For many people, risk is part of the fabric of their life. The issue is how to handle risk and how to minimize the impact of a risky situation, and this is a complex problem in a society which tends to blame people who take health risks.

That is why we need to renew our discourse by adopting a non-judgmental harm reduction approach to sexual risk reduction. We should assume that, with few exceptions, HIV-negative people do not want to get the virus and that people living with HIV do not want to transmit the virus. The greatest concern of people living with HIV is ongoing HIV transmission. People do care. People who take risks do also care. There are many strategies that people use to reduce their risk of acquiring or transmitting HIV. Some women use diaphragms because these methods are discreet. Among HIV-positive individuals, serosorting is frequently observed. Gay men have been observed to adopt their sexual practices through strategic positioning. Of course, the effectiveness of these strategies is uncertain. The point is that people who have problems with condom use do care at some level, or else they would not bother to use alternative strategies. That is why we need to move beyond the all or nothing approach to HIV prevention and better investigate the effectiveness of risk reduction approaches.

The viral load suppression is a typical example of sexual risk reduction strategy. This slide shows the results of the study that measured the rate of infection among untreated serodiscordant heterosexual couples. Transmission rates are almost linearly associated with the level of viral load. In a Spanish cohort of serodiscordant couples, transmission was reduced by 80 percent after introduction of HAART. In this study, transmission never occurred when viral suppression was achieved in the positive partner.

How these results can be applied to the prevention of sexual transmission is still a matter for debate. Last year, a statement issued by Swiss experts became the subject of much controversy. They concluded that condom use may not be necessary in stable heterosexual, serodiscordant couples in which viral load control had been achieved in the positive partner for at least six months. Many concerns were raised about this statement. Virological suppression in the blood does not necessarily mean suppression in the genital fluids. In addition, the doctor in this report referred to stable heterosexual couples only. Despite these limitations, the results of the Swiss study may hold promise for serodiscordant couples, the population in which most transmission occurs in high-prevalence countries.

It is not, however, clear how these results might apply to other populations exposed to HIV. ART should, however, be retained as a useful, additional risk reduction strategy. But more research is needed to determine its contribution to combination prevention. Interestingly, the Swiss controversy raises the question of when to start ART. Recent muddling results provide a compelling argument that increasing the 200 CD4 threshold globally recommended for initiating ART could lead to a dramatic reduction of HIV incidence even when considering an increase in risky behavior.

Moreover, in two different studies carried out by my research group and funded by ANRS, one conducted in Côte d'Ivoire and the other in Cameroon, we were able to demonstrate that access to ART increases consistent condom use among sexually active people living with HIV. Consistent condom use is about twice as high in people receiving ART. Such results can probably be explained by the care and support provided to patients who are treated.

Supporting people living with HIV who do not need treatment by providing them with appropriate prevention, care, and counseling services is a huge need. In most contexts, these people are not a priority of interest to healthcare workers as they are not eligible for treatment and, in turn, do not receive psychosocial support. [Where] their own support programs have already been introduced in several settings, they have been shown to be highly efficient. Similar approaches could be helpful to design new behavioral interventions based for individuals living with HIV, but not yet treated. This would, in turn, empower people to reduce risky behaviors.

For people living with HIV on their treatment, all interventions that maintain adherence and long-term virological success can have an impact on HIV transmission. Multidisciplinary cohorts show that ART-related side effect is a significant factor in influencing adherence and condom use. The more side effects we experience, the less adherent we are, and the less likely we are to use condoms. Taking into account the patients reported outcomes, including quality of life, could help when designing the best strategies to reduce viral load and risky behaviors. And that approach, including comprehensive prevention, is needed.

Here are two examples about the relationship between perceived toxicity and inconsistent condom use. On the left, in French, drug users living with HIV, and on the right, in people living with HIV in Côte d'Ivoire, we found that perceived toxicity had similar effects on inconsistent condom use.

Now I would like to turn your attention to the second topic today, and that is diversifying HIV testing approaches. There are many benefits of knowing one's HIV status. For the individual, shortening the duration of the unknown infection period can have an impact on clinical outcomes. From a public health point of view, those who know they are infected are more likely to adopt several behaviors.

A meta-analysis indicated that the prevalence of unprotected intercourse was reduced by 53 percent in HIV-positive persons who were aware of their status, relative to those who were unaware. However, in most settings, HIV diagnosis occurs late with multiple negative consequences.

In order to enable more people to get tested and treated, we need to combine several HIV testing approaches, provider initiated testing, with an opt-out option has led high prevalence countries to significantly higher rates of HIV detection. Stigma, fear of receiving a positive result, issues of confidentiality, and poor access to testing sites are the barriers to the voluntary counseling testing approach. Alternative delivery models, such as mobile vans, can also increase access to an uptake of testing.

On this slide, you can see the mobile community van of our Moroccan partner, and despite the low HIV prevalence in this country, such mobile testing strategies have been shown to be effective in reaching HIV-infected individuals.

We therefore need to further explore the added public health value of community testing. Intervention based on rapid HIV testing performed by non-healthcare professionals may reach the most marginalized populations more efficiently. In addition, the combination of peer-based counseling and rapid testing could represent an interesting preventive strategy to enable repeat testing for individuals at risk who are discouraged from seeking services.

We should also not forget the importance of primary HIV infection in the dynamics of transmission. This graph shows the natural history of HIV infection. For each phase, primary infection, asymptomatic phase, and AIDS, you can see the average risk of transmission per coital act which is highest during primary infection when viral load is elevated.

Transmission during primary infection may account for approximately half of onward transmissions. Such data suggests that seroignorance during the early stages of infection makes a significant contribution to transmission. Strategies to increase access to HIV testing should also make provision for repeat tests, especially for people who are often confronted with risk.

The third and final area of my talk is to discuss how we can become more effective when dealing with stigma, which continues to represent a major barrier to HIV prevention.

There is growing evidence that stigma and discrimination contribute to risky behaviors in positive and negative individuals. In several parts of the world, the fear of stigma is associated with lower uptake of HIV testing and less willingness to disclose positive results. Recent data from the French ANRS-VESPA study show that experience of discrimination is associated with risky health behaviors, such as unprotected sex and non-adherence.

More specifically, we can see the relationship between inconsistent condom use and experience of discrimination. Among heterosexuals and injecting drug users, discrimination in the social environment significantly predicts inconsistent condom use.

A related problem is double stigma. Some groups are already more susceptible to HIV infection. This is the case for injecting drug users, sex workers, and MSM. These groups are already stigmatized independently of HIV infection. Such stigma may contribute to the high level of HIV prevalence in these groups, as stigma constrains access to information and to services. Yet, these groups are in greatest need of services and care. On this slide, you can see the comparison of HIV prevalence in MSM, with those in the general population in several countries. In MSM, the prevalence is always much higher.

To end my talk, I would like to propose an effective treatment combination therapy to fight against stigma. The proposed regimen must include the following: first, fighting for better acceptance of people living with HIV; second, improving relevant laws and policies; and third, involving prevention users working with people, rather than for people. Greater acceptance of HIV in our society will help people break the secret and disclose their status without fear.

In our experience with AIDES several of our frequent partners, we have found that strengthening the social positions of people living with HIV reinforces the collective ability to talk about HIV. It induces changes in the way society regards people living with HIV. Of course, the ability to talk is associated with the ability to listen. That is why public action is necessary.

This is an example of a campaign you have probably seen during this week. Its advantage is that it makes people think about how HIV could impact one's attitudes. This campaign has been popular in terms of capturing the audience attention. With public testimonies of people living with HIV, it can change the representation of HIV in the general public.

The use of political leaders in this campaign is also of interest. Here you see a poster we use in France during the last presidential election, as well as a poster which features the current French Minister of Health.

The second element is improving laws and policies. Instead of fighting drug users, gay men, sex workers, and immigrants, laws should protect all groups who are more vulnerable to, or at risk, of HIV. Believe it or not, in my own country, France, AIDS prevention activists are now legally blacklisted by the police. Right now, any person in France who attends AIDS community-based organization can be registered in a police database collecting sexual orientation and serological status.

Such antidemocratic practices have never happened since World War II in my country. All over the world, several societal factors still contribute to the spread of the epidemic. Fortunately, several Latin American countries have launched policies and programs geared towards reducing stigma, such as homophobia. Such policies need to be introduced in other settings, particularly in Africa where community prevention work can be very risky. We have lived this recently in Uganda and in Senegal with the imprisonment of gay prevention activists.

Similarly, the repression of drug users in several countries runs counter to the public health interest. Changes will be possible if international institution, especially financial backers, put the maximum pressure on governments to guarantee a rights-based approach to public health.

Community mobilization among people living with HIV has been shown to be a driving force in increasing access to treatments. It should become a driving force also to improve HIV prevention by involving HIV-positive people, as well as those who are most exposed to infection. There must be a real effort to make sure that those living with HIV, or those living with risk, are truly involved, occupying key positions. The mobilization of people who are seroconcerned is necessary since professional response will never be sufficient.

For the last 25 years, prevention uptake has improved through community mobilization and peer support, leading towards the empowerment of most who are marginalized and most at risk. This slide shows people who are not infectiologists, not immunologists, not sociologists; they are simply nothing-ologists at work.

But these people are, in fact, life-ologists since their expertise is based on their life experience. On the slide, you can see peer-based gay prevention activities, harm reduction tools including those conceived by drug users themselves, and mobilization of migrant women who show the advantage of female condoms in their community.

I would particularly like to underline the role of mobilization of sex workers all over the world. Such mobilization has led to success in prevention programs in India, in Central America, in my own country of France, where female transgender sex workers have successfully worked together for many years.

Finally, a new important event in the field of mobilization is the open emergence of gay men in African contexts. Until recently, MSM were ignored by African and international policy makers. It was argued that gay men do not exist in Africa, or are very few. AIDES has recently supported the mobilization of gay Africans, and I must say that it was not difficult. We learned that gay men are not so few and not so invisible. They want to contribute to public health policies, and can become community health actors, despite homophobic environments.

In conclusion, prevention can work when it reflects the comprehensive needs of people. In generalized epidemics, more research is needed to understand how to mobilize those most at risk, but empowerment of communities is a global challenge. To do so, real empowerment of people living with HIV, or people living with risk, is needed. My message is: Please involve us, the seroconcerned person, the lay men and women in public health action. With this aim, four non-governmental organizations based on community involvement and acknowledgement of acquired expertise have decided to create a new, international structure called Plus. At the moment, these four organizations are ALCS in Morocco, ARCAD in Mali, and COCQ-Sida in Quebec, and AIDES in France. The aim of Plus is to bring the voices of sero concerned people to influence international policy makers. I would like to thank, of course, all the volunteers and staff members of AIDES and all groups of collaborators I have the pleasure to work with in my double life of scientist and activist. Thanks, particularly, to the French ANRS, as without its existence, no multi disciplinary work could be possible in my country. Thank you for your attention.

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